Lessons for healthcare from emerging markets

Can the vision of
emerging markets transfer to developed countries for better healthcare?

From the mobile banking
revolution and use of healthcare drones in Africa to production-line surgery in
India, emerging markets embrace tech innovation with speed and boldness that
developed markets only dream of. The reasons are many including a lack of
infrastructure and regulations, factors that lend themselves to finding
solutions and thinking outside the box. Technology developed in regions like
Europe and North America has spawned opportunities in healthcare around the
globe. Now is it time for developed markets to learn from emerging markets? We
asked three healthcare experts to reflect on the question: "Does
production-line surgery have potential in developed healthcare markets?"

Sir Muir Gray, CBE

Director, Better Value Healthcare Oxford, UK, Professor

of Knowledge, Management, University of Oxford, UK,

Chief Knowledge Officer, Department of Health UK

HealthManagement - EXEC Editorial Board Member

“The development of what is called production-line surgery in countries where resources are very limited is of great interest, but production-line surgery has already been developing in wealthy countries too.

There has been a
concerted effort to reduce duration of stay and then to make as many operations
day case operations as is thought to be possible. This is called increasing
productivity but it is important to remember that productivity is different
from efficiency. Productivity is measured by relating the resources used to the
outputs, for example numbers of operations or surgeon or operating theatres
whereas efficiency relates outcome to resources, for example the percentage of
people having an operation whose health improved significantly related to the
resources used. This is obviously very important in every country because need
and demand will increase faster than resources. However the key issue is now
value. It does not make sense to carry out operations of low value even if they
are carried out efficiently and productively. Doing the wrong things at less
cost is not high value healthcare.

But what is high value
surgery? Well that depends upon a number of factors and the population level.
It depends on factors such as:

How
much resource is being used for surgery and could that resource be used better
for medical treatment or prevention?

Are
the people who would benefit most from surgery being operated on or, even in a
tax based system, are wealthier people having more operations than deprived
sections of the population?

Some interventions where
there is limited evidence of cost-effectiveness, for example shoulder, surgery
and knee arthroscopy, have increased in wealthy countries in the last decade
but this is not necessarily high value use of resources when the alternative
use of resources is taken into account.

Even interventions where
there is strong evidence of effectiveness, for example hip replacement, knee
replacement and cataract surgery may start to yield a poor return in investment
if numbers treated significantly increase and therefore if the operation is
offered to people who are less severely affected. For such people the benefits
of the operation are less than they are for people who are very severely
affected, the type of people treated when the operation was introduced, but the
probability and magnitude of harm is constant. Therefore the balance of benefit
to harm is significantly different for people who are mildly affected compared
to those who are severely affected.

This means that even hip
replacement, the operation voted the number one operation in the 20th century,
may not give good value to either individuals or populations if too many
operations are carried out in a particular population.”

“Emerging markets
will be a catalyst for disrupting how surgical care is delivered more
affordably in developed markets.

Hospital systems in India, like
Narayana Healthcare, have already demonstrated the value of 'production-line
surgery' to enable more surgeons to perform more surgeries more effectively.
Their flagship hospital has over 5, 000 beds, sees thousands of patients a day,
and performs over 30 cardiac procedures a day. They achieve this because of
their team-based approach to surgical care, where top surgeons, recognising the
practical limitations of an individual surgeon, have transitioned their role
from 'super-hero' to 'team coach'. Focus is placed on team training, supply
chain, and strategic partnerships with equipment and technology suppliers.

This production-line surgery
approach is borne out of necessity, as there are simply too many underserved
patients to take a traditional approach to surgical workflow and patient care.
But greater volume doesn't necessarily mean lower quality results. On the contrary,
procedure volume has enabled surgeons to become highly skilled and foster
continuous improvement - Narayana's clinical outcomes rival and exceed some of
the best hospitals in the U.S.

Other hospital groups in India
like Apollo, Fortis, and Aarvind Eye Institute have similar models of high
quality, affordable care driven by patient volume and creative business models.
In a slightly different model, Columbia Asia, a hospital group in Southeast
Asia known as the 'McDonald's of hospitals', has optimised each of their 30
hospitals to be around 100 beds, following a manufacturing model of replicating
an operation unit with amazing cost-efficiency.

Production-line surgery has the
ability to democratise surgical care in developed markets such as United States
or the EU. With ever increasing cost of surgical care without similar increases
and clinical outcomes, a production-line surgery approach could have great
benefit for high-volume procedures such as total knee replacement or cataract
surgery. More complex surgical cases (ie oncology or neurosurgery) don't need
production surgery in practice but the foundational philosophies of mentorship,
team training, strategic partnerships, and data enabled decision-making will
still provide great benefit to improving outcomes and patient satisfaction
while reducing overall cost of care.”

Umesh Prabhu

Former Medical
Director, Wrightington, Wigan and

Leigh NHS
foundation Trust & Bury Trust, UK

“Healthcare must be
safe, good quality and good value for the money. In many ways the National
Health Service (NHS) in England is relatively safe, good quality and, compared
to many other western societies, it is very good value for the money. However,
demand is increasing, people are living longer and longer and cost of providing
good healthcare is increasing. So even the NHS has to find a way of reducing
costs. This is where production-line surgery has huge potential.

The phrase production-line
surgery itself is not accurate. What we are talking about is a large volume of
elective surgical work done at a very low cost. This concept originated in
Russia and has now taken over in India, for example, at the Narayana Heath and
Aravind Eye Hospitals. Each day, nearly 700 cataract surgeries are completed at
these facilities and well-trained, low-paid staff undertake most of the
procedure. The surgeon executes only the most delicate aspect of the surgery.
The safety and quality of care are maintained by excellent support for staff,
good teamwork and regular feedback to personnel. IT is used to make sure
procedures are done quickly and effectively and results are analysed regularly
and shared with the team.

The volume of surgery means the
hospital is able to negotiate the cost of consumable goods. This reduces the
cost of procedures. Nearly 60 to 70 percent of NHS costs are salaries and if
low-paid staff carry out most of the procedures safely, this would reduce
personnel costs significantly.

Today, the NHS is finding it
difficult to cope with increasing demand and during winter many elective
surgeries are cancelled. The waiting lists are growing in various parts of the
country and the demand is increasing. Cost of care will also increase.

The NHS has to find alternative
ways of reducing costs and increasing productivity without compromising quality
and safety. This needs a team of good doctors, nurses, managers and other staff
to work together and staff must be trained very well. The procedure should also
be piloted in one or two elective hospitals. I have absolutely no doubt that
this can save millions of which the NHS can invest in social care, community
care, primary care, digital transformation and another areas where NHS
desperately needs investment.”

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emerging markets, developed markets, healthcare, innovation, production line surgery
We asked three healthcare experts to reflect on the question: "Does production line surgery have potential
in developed healthcare markets?"

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